This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.emblemhealth.com or by calling 1-800-624-2414. Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles Yes for specific services? Is there an out of pocket No limit on my expenses? What is not included in the out of pocket limit? Is there an overall annual limit on what the plan pays? Does this plan use a network of providers? $200 individual/$500 family for outof-network only. Co-payments, premiums, balancebilled charges, and health care this plan doesn't cover. No Do I need a referral to see a No specialist? Are there services this plan Yes doesn t cover? City of New York CBP Basic Program Yes. See www.emblemhealth.com or call 1-877-842-3625 for a list of participating providers. You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services. Not applicable because there s no out-of-pocket limit on your expenses. Even though you pay these expenses, they don t count toward the out of pocket limit. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-ofnetwork provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. You can see the specialist you choose without permission from this plan. Some of the services this plan doesn t cover are listed on page 4. See your policy or plan document for additional information about excluded services. 1 of 7
Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use in-network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event Services You May Need Your Cost If You Use a Your Cost If You Use a Non- Limitations & Exceptions If you visit a health care provider s office or clinic If you have a test If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.emblemhealth.com. Primary care visit to treat an injury or illness $15 co-pay/visit 0% co-insurance ----None---- Specialist visit $20 co-pay/visit 0% co-insurance Does not apply to all specialists. Other practitioner office visit $15 co-pay/visit 0% co-insurance ----None---- Preventive care/screening/immunization $15 co-pay/visit 0% co-insurance For annual physicals, you must be 45 years old or older. Diagnostic test (x-ray, blood work) $15 co-pay/visit 0% co-insurance ----None---- Imaging (CT/PET scans, MRIs) $15 co-pay/visit 0% co-insurance Pre-certification required. Generic drugs Not covered Not covered ----None---- Preferred brand drugs Not covered Not covered ----None---- Non-preferred brand drugs Not covered Not covered ----None---- Specialty drugs Not covered Not covered ----None---- 2 of 7
Common Medical Event Services You May Need Your Cost If You Use a Your Cost If You Use a Non- Limitations & Exceptions If you have outpatient surgery If you need immediate medical attention If you have a hospital stay If you have mental health, behavioral health, or substance abuse needs If you are pregnant Facility fee (e.g., ambulatory surgery center) Not covered Not covered Please check with your employer. Physician/surgeon fees Covered 0% co-insurance ----None---- Emergency room services Not covered Not covered ----None---- Emergency medical transportation Not covered 20% co-insurance ----None---- Urgent care $15 co-pay/visit 0% co-insurance ----None---- Facility fee (e.g., hospital room) Not covered Not covered ----None---- Physician/surgeon fee Covered 0% co-insurance ----None---- Subject to New York City nonparticipating benefit $200/$500 Mental/Behavioral health $15 co-pay/visit outpatient services calendar year deductible No lifetime maximum Mental/Behavioral health inpatient services Substance use disorder outpatient services $300 co-pay per admission $15 co-pay/visit $500 co-pay per admission/$1 maximum per calendar year Subject to New York City nonparticipating benefit $200/$500 calendar year deductible 20% to max of $2,000 per person per calendar year No lifetime maximum Substance use disorder $500 co-pay per admission/$1 $300 co-pay per admission inpatient services maximum per calendar year ----None---- Prenatal and postnatal care No charge 0% co-insurance ----None---- Delivery and all inpatient services No charge 0% co-insurance ----None---- 3 of 7
Common Medical Event Services You May Need Your Cost If You Use a Your Cost If You Use a Non- Limitations & Exceptions If you need help recovering or have other special health needs If your child needs dental or eye care Home health care No charge $50 deductible per episode; 20% coinsurance Pre-certification required. 200 visits per member per year. Rehabilitation services $15 co-pay 0% co-insurance Habilitation services $15 co-pay 0% co-insurance 16 visits per calender year Skilled nursing care Not covered Not covered ----None---- Durable medical equipment $100 deductible $100 deductible; 50% of usual and Pre-certification required on greater customary charge than $2,000 Hospice service Not covered Not covered ----None---- Eye exam Not covered Not covered ----None---- Glasses Not covered Not covered ----None---- Dental check-up Not covered Not covered ----None---- Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn t a complete list. Check your policy or plan document for other excluded services.) Acupuncture Cosmetic surgery Dental care Hearing aids Long-term care Routine eye care Routine foot care Weight loss programs Benefits paid as a result of injuries caused by another party may need to be repaid to the health plan or paid for by another party under certain circumstances. Other Covered Services (This isn t a complete list. Check your policy or plan document for other covered services and your costs for these services.) Bariatric surgery Chiropractic care Infertility treatment Non-emergency care when traveling outside the U.S. Private-duty nursing 4 of 7
Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact EmblemHealth at 1-800-624-2414. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov. Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact EmblemHealth. All hospital grievances should be mailed to: EmblemHealth-Hospital Grievance P.O. Box 2828 New York, New York 10116-2828 All other grievances should be mailed to: EmblemHealth-Grievance Unit P.O. Box 1701 New York, New York 10023-9476 Oral Utilization Review Appeals can be initiated by calling toll free 888-906-7668. Language Access Services: City of New York CBP Basic Program Spanish (Español): Para obtener asistencia en Español, llame al 1-800-624-2414. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-624-2414. Chinese ( 中 文 ): 如 果 需 要 中 文 的 帮 助, 1-800-624-2414. Or you may submit a written appeal to: EmblemHealth Utilization Review Appeals P.O. Box 2809 New York, NY 10116-2809 You may also obtain an external appeal application from: The New York State Department of Financial Services at 1-800-400-8882, or its Web site (www.dfs.ny.gov/), or The EmblemHealth Medical/Utilization Review Department at 1-877-482-3625 Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-624-2414 To see examples of how this plan might cover costs for a sample medical situation, see the next page. 5 of 7
Coverage Examples Coverage for: Individual/Family Plan Type: PPO About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Having a baby (normal delivery) Amount owed to providers: $7,540 Plan pays $7315 Patient pays $225 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles $0 Co-pays $75 Co-insurance $0 Limits or exclusions $150 Total $225 Note: These numbers assume the patient has given notice of her pregnancy to the plan. If you are pregnant and have not given notice of your pregnancy, your costs may be higher. For more information, please contact: 1-800-624-2414. Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays 4125.47 Patient pays 1274.53 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductibles $0 Co-pays $535 Co-insurance 0 Limits or exclusions $739.53 Total 1274.53 Note: These numbers assume the patient is participating in our diabetes wellness program. If you have diabetes and do not participate in the wellness program, your costs may be higher. For more information about the diabetes wellness program, please contact: 1-800-624-2414. 6 of 7
Coverage Examples Coverage for: Individual/Family Plan Type: PPO Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don t include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren t specific to a particular geographic area or health plan. The patient s condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from innetwork providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and co-insurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn t covered or payment is limited. Does the Coverage Example predict my own care needs? û No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor s advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? ûno. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? üyes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? üyes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-of-pocket costs, such as co-payments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. 7 of 7